Robert A. Moore, M.D.

Case Report

A 26-year-old female presented with marked sweating which interfered with her life. She had sought previous care and was advised to use aluminum chloride hexahydrate (Drysol), which caused skin irritation. The patient saw an ad on the internet promoting endoscopic thoracic sympathectomy and presented for a medical opinion about the procedure. After reviewing the evidence on efficacy of the sympathectomy, the patient elected to forego further therapy.

Discussion

Sweat, a needed life function, is produced by two types of sweat glands. Eccrine glands are located all over the body and secrete fluid onto the surface of the skin. There are 2-5 million eccrine glands which are stimulated by the autonomic nervous system particularly in response to exercise, hot weather, and nervousness. The primary function of sweat production by the eccrine glands is to cool the body. The second type of sweat glands are apocrine (a fatty sweat) which are located in hair follicles on the scalp, axilla, and genital area. They are stimulated under emotional stress. Sweat secreted by apocrine glands may be broken down by bacteria and lead to a strong odor. Other caused of increased sweating include spicy foods, excess thyroid hormone, menopause, hypoglycemia, fever, infections, and serious body complications such as a heart attack. Complications of generalized excess sweating include fungal infections and heat rashes.^1,2

Hyperhidrosis or excessive sweating is sweating beyond that needed to regulate increased body heat. It may be secondary to other causes (i.e. excess thyroid hormone). Most instances of secondary hyperhidrosis are managed by resolving the precipitating cause. Various conditions and/or situations that may cause secondary hyperhidrosis include neurological causes

i.e. Riley-Day Syndrome, irritative hypothalamiclesions, drugs such as physostigmine and tricyclic antidepressants, and gustatory causes such as spicy foods.^1,2

Primary hyperhidrosis occurs in 0.6%-1% of the population. Onset of primary hyperhidrosis is often in adolescence. The cause is unknown but may be genetic. This form hyperhidrosis primarily involve the palms and soles. It can interfere with various aspects of life, as the hands are always wet.^1,2

Management of Hyperhidrosis

The initial treatment for milder forms of hyperhidrosis should focus on life-style modifications such as daily bathing to decrease bacteria on the skin, thorough drying of the feet, use of cotton or wool socks, rotating shoes, airing feet, wearing of clothes that breathe (cotton, wool, silk), practice relaxation techniques, and use perfume-free antiperspirants.³ Topical agents such as aluminum chloride products (Drysol) may also be used. Other agents such as 2-5% tannic acid solution, 5-20% formalin solution, and 10% glutaraldehyde can be useful but may have more side effects such as staining and skin sensitization.^1,2

Anticholinergics are logical therapeutic agents because the acetylcholine is the chemical mediator in the autonomic nervous system. Ditropan, benztropine, propantheline, methantheline bromide, and scopolamine patches have been used with partial success. Side effects may include mydriasis and bladder/bowel dysfunction. Surprisingly, tricyclics actually cause increased sweating. Clonidine, an alpha-adrenergic stimulant, has been beneficial. In spinal injury patients, anecdotal reports of benefit included the use of propoxyphene and fludrocortisone acetate. Tranquilizers to reduce the anxiety-nervousness stimulation component of increased sweating are also

used.^1,2,4-6

Botulinum toxin, which is promoted by dermatologist and plastic surgeons for cosmetic surgery and by neurologists for muscular dystonias, is also used for hyperhidrosis. It inhibits the release of acetylcholine that is involved with sweat gland stimulation. A recent randomized study involving injection in one axilla compared to placebo in the other showed marked benefit. The results decreased with time but still had some effect at 24 weeks. Nearly all of the patients (98%) said they would recommend this treatment. It should be noted that the benefit is to localized areas, and treatments have to be repeated.^1,2,7-11

Iontophoresis is the introduction of an ionized substance through the intact skin by the application of direct current. The initial report of iontophoresis as a treatment for hyperhidrosis was published in 1936 but it was not widely utilized until 20-25 years later. It is primarily beneficial in localized areas such as palms or soles. A study comparing iontophoresis to topical tannic acid application showed favorable results. However, treatments are to localized areas with short duration of benefits.^1-3,12,13

Surgical Treatment

Local removal of sweat glands in the axilla has successfully been performed. The area in the axilla may be small or extensive. Identification mapping may be done by tissue paper draping and by starch-iodine techniques.^14-16

Liposuction is a variation of the local surgery concept and has been done for the past 25 years. The combined use of starch-iodine technique and tumescent liposugery is considered to be safe and efficient.^14-20

Sympathectomy is considered the new standard by which all other treatments are judged. Originally this was an open surgery with removal of T-2, T-3, and possibly T-4 sympathetic chain. Several surgical approaches are involved. Transthoracic endoscopic surgery has been utilized since 1994. It dos not require a thoracotomy and can be preformed as an outpatient procedure under general anesthesia.^{1,2,14-16,21-27} Sympathectomy is generally used for patients with primary hyperhidrosis with severe symptoms that limit normal daily activities. Conservative therapy should have already been tried prior to undergoing sympathectomy. A major limitation to the surgery is that the results are limited to the body region corresponding to the nerve level involved. Thus plantar symptoms are not be aided by thoracic sympathectomy. Other limitations or side effects include increased compensatory sweating in the areas of the body not supplied by the nerves severed, gustatory sweating (increased facial sweating with eating), and phantom sweating (the sensation of sweating without actually sweating). Surgical complications can also occur such as Horner's syndrome, pneumothorax or brachial plexusus injury. In lumbar sympathectomy for plantar sweating, sexual dysfunction can occur.^1,2,21-27